Healthcare Provider Details

I. General information

NPI: 1275602922
Provider Name (Legal Business Name): JOHN NMN YASENCHAK ED. D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 WABANAKI WAY
INDIAN ISLAND ME
04468-1252
US

IV. Provider business mailing address

23 WABANAKI WAY
INDIAN ISLAND ME
04468-1252
US

V. Phone/Fax

Practice location:
  • Phone: 207-817-7400
  • Fax: 207-827-5022
Mailing address:
  • Phone: 207-817-7400
  • Fax: 207-827-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLC 1226
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: